The controversial decision of the United States Preventative Services Task Force (USPSTF) to recommend against screening men for prostate cancer has prompted a healthy debate regarding the utility of the early detection of this cancer. Despite our best efforts for early detection, prostate cancer remains the second leading cancer cause of death in men, killing approximately 34,000 men each year. Tens of thousands of additional men suffer from the burden of painful metastatic prostate cancer, which can lead to bone fractures, the inability to urinate, spinal cord compression and renal failure; this disease is not entirely benign. Rather than taking the drastic step of eliminating PSA screening entirely, modifying its application can maximize benefit while reducing overtreatment and adverse side effects.
Pros of PSA Screening
• Currently, physicians only have two methods available for prostate cancer screening: PSA tests and digital rectal exams (DRE).
• Since the widespread adoption of PSA screening in the early 1990’s, there has been a 39% reduction in prostate cancer mortality rates.
o We are now able to diagnose prostate cancer earlier, while in a more treatable stage. Before the PSA test, prostate cancer tended to be diagnosed at more advanced, less treatable stages.
• Prostate cancer mortality is now the lowest it has been since the 1930’s, when life expectancy was much lower. No other significant changes in the management of prostate cancer were made in this time to explain the decrease.
Cons of PSA Screening
• PSA screening may result in over-diagnosis, but that does not necessarily mean over- treatment. This is where the experience of your doctor comes into play.
• PSA tests should be used in high risk men only including, but not limited to:
o Men of African American descent,
o Men with a family history of prostate cancer.
o These groups should begin screening at age 40, followed by annual tests.
• PSA is not a perfect test – it is not capable of determining which cancers will progress and which are clinically insignificant.
o This is why it is important to not just look at single test result, but to also look at PSA trends, co-morbid conditions, overall life expectancy and understand patients’ treatment goals.
The debate over PSA screening has highlighted the importance of the need for physicians to practice individualized medicine rather than reflexive medicine. It is true that PSA is not an appropriate test for men of all ages, but these decisions should be based on each individual patient. PSA testing does not automatically lead you down the road to treatment – information is better than ignorance. For more information, please visit my website.
